Cardio-Oncology Mediterranean group
Immune checkpoint inhibitors
(e.g., nivolumab, pembrolizumab, cemiplimab, avelumab, atezolizumab, durvalumab, ipilimumab, tremelimumab)
ECG, Troponin*, Natriuretic peptides
before cancer treatment begins
Consider one of the two strategies according to local skills ans resources
Strategy 1 (preferred)
ECG AND Troponin*
within 48h before each administration AND
Check (by the oncologist)
for new CV symptoms/signs
before each administration AND
Cardio-oncology evaluation** every year
ECG, troponin,* Natriuretic peptides
if new CV symptoms/signs OR
if other irAEs occur
Strategy 2 (alternatively)
Check (by the oncologist)
for new CV symptoms/signs
before each administration
AND
Cardio-oncology evaluation** every year
ECG, troponin,* Natriuretic peptides
if new CV symptoms/signs OR
if other irAEs occur
New cardiovascular symptoms/signs OR
Troponin+* OR
ECG abnormality
Suspect myocarditis or other CV irAEs
Withhold immunotherapy
Refer to a cardio-oncology unit (preferably) or cardiology department for monitoring and diagnostic work-up
*For monitoring, troponin testing should be carried out by the same laboratory (same type of troponin, same method of measurement). Troponin testing is considered as positive if troponin I or T >99th percentile of the upper reference limit. Concomitant myositis may result in significant elevations of CK, CK isoforms, and even troponin T. Thus, troponin I would be the most specific option for myocardial injury. CK-MB should be used if troponin I measurement is not available. In patients with pretherapeutic troponin elevation, a 50% increase of the level may be used as a cutoff, but no evidence currently supports this recommendation.
irAEs=immune-related adverse events
**A cardio-oncological evaluation will systematically include at least one visit with blood pressure, blood glucose, lipid profile, GFR calculation, ECG and trans-thoracic echocardiography (TTE). Measurements of global longitudinal strain and 3D LVEF (if feasible) are recommended with the same machine.
**Assays should be carried out by the same laboratory (same type of troponin, same method of measurement).
Troponin + if >99e percentile of the URL
CV = cardiovascular; irAE = immune related adverse event